0008-3194/2002/257-264/$2.00/©JCCA 2002

Locating and treating low back pain of myofascial origin by ischemic compression Guy Hains, DC*

The purpose ofthis article is to describe a method to L'objectifde cet article est de decrire une methode identify and treat triggerpoints ofmyofascial origin by d'identification et de traitement des points de ischemic compression among patients with low back fibromyalgie d'origine myofaciale a' l'aide de pain. In addition to a review ofthe literature, the author compression ischemique chez les patients qui souffrent draws upon his own clinical experience to accomplish de lombalgie. En plus de 1'examen de la documentation this goal. In general, thumb pressure is usedfor the scientifique, I'auteur puise dans sa propre experience identification, localization and treatment oftrigger clinique pour atteindre son objectif En general, les points and tender spots within the muscles ofthe lumbar, pressions digitales s'utilisent pour identifier, localiser et pelvic, femoral and gluteal areas. The management of traiter les points defibromyalgie et autres zones low back pain ofmyofascial origin by ischemic sensibles musculaires des regions lombaire, pelvienne, compression can be used in any setting, without the need femorale etfessie're. Le traitement de la lombalgie ofspecialized equipment. In addition to clinical d'origine myofaciale par la compression ischemique effectiveness within a wide range ofsafety, this peut etre utilise en toute circonstance, nul besoin approach is easy on the practitioner and well tolerated d'equipement specialise'. En plus de l'efficacite clinique by the patient. et de la grande innocuite qu 'elle offre, cette methode est (JCCA 2002; 46(4):257-264) facile a' utiliser pour le praticien et bien toleree par le patient. (JACC 2002; 46(4):257-264)

KEY WORDS: low back pain, trigger points, myofascial MOTS CLES : lombalgie, points de fibromyalgie, douleurs pain syndrome, ischemic compression, chiropractic. myofaciales, compression ischemique, chiropratique.

Introduction low back pain include: non prescription analgesics; pre- Low back pain is the most common and costly neuro- scribed pharmaceuticals; electrical modalities; acupunc- musculoskeletal (NMS) dysfunction in contemporary soci- ture; shoe lifts; low back corsets and back belts; patient ety,1 and the most common reason for a patient to present education and; manual procedures including soft tissue to a chiropractor's office.2'3 Over 80% of adults suffer therapy, mobilizations, and spinal manipulative therapy.6'7 from spinal pain at some time in their lives, affecting both Although joint dysfunction, disc disease, degenerative ar- a person's physical abilities as well as their psychosocial thritides, sprains, strains and other disorders associated health.4'5 Within health care circles, a number of different with the position or movement of the spine (such as those approaches are used to manage patients so afflicted, with caused by scoliosis or spondylolisthesis) are all recognized variable results. Therapeutic approaches used to manage common causes of low back pain,8 the role of muscular

* Private practitioner, Trois-Rivieres-Ouest, Quebec. C JCCA 2002. J Can Chiropr Assoc 2002; 46(4) 257 Low back pain

disorders are often under appreciated. However, some ex- ger points in order to diminish myofascial pain syn- perts, such as Simons and Travel9 maintain that myofascial dromes. Ultrasound and transcutaneous electrical nerve irritations are very common causes of low back pain, emi- stimulation (TENS) have reportedly been used to success- nently treatable by a skilled practitioner, and should there- fully manage patients with low back pain of myofascial fore be considered in all chronic pain patients. origin and for fibromyalgia.2022 Furthermore, several In addition to a brief review of the literature, the author studies have reported clinically important results using draws on his own clinical experience in order to describe more invasive procedures such as injection or acupunc- an approach to identify, localize and treat low back pain of ture needling of trigger points.20'2326 myofascial origin using ischemic compression technique. Kovacs and his colleagues8 recently revealed their results of a randomized, double-blinded controlled multi- Literature search center clinical trial assessing the efficacy of neuro- Using a standard search strategy, the author sought to reflexotherapy in the management of low back pain. In identify articles describing the treatment of low back pain this study, Kovacs et al. assigned patients with chronic of myofascial origin using ischemic compression. Key low back pain into either a control group (n = 37) or treat- words used for the search of health care databases ment group (n = 41). The treatment group intervention (Pubmed, Mantis, Medline, CINAHL) were: low back was characterized by temporary implantation of epider- pain/ myofascial pain syndrome/ ischemic compression/ mal devices in trigger points in the low back at the sites of and chiropractic. dermatomes clinically involved in each case, as well as Surprisingly few articles were found using this search referred tender points of the ear. The control group re- strategy. Several articles from the late 1980s and early ceived a sham treatment consisting of placement of the 1990s reported that trigger point therapy would be useful same number of epidermal devices to within a 5 cm radius for patients with low back pain originating from of the target zone. Patients were allowed to continue with myofascial structures, sacroiliac dysfunction, disc hernia- their pain medication, the use of which was monitored tion, or cases of assumed neurologic involvement as evi- during the trial. Evaluations were performed five minutes denced by a positive straight leg length test.104 before the intervention, five minutes immediately after the Two more recent articles were case reports of the treat- intervention, and 45 days later. Patients in the treatment ment of the quadratus lumborum (QL) muscle associated group showed immediate lessening of pain compared to with low back pain.' '16 In one article, DeFranca and patients in the control group. The pain relief was clinically Levine15 describe the successful resolution oftwo patients relevant and statistically significant.8 suffering from low back pain, flank pain, buttock and lat- In addition to low back pain, the author of this article eral hip pain using myofascial therapy aimed at restoring has recently found ischemic compression techniques to QL muscle length and function, coupled with spinal ma- also be effective in the treatment of fibromyalgia,27 shoul- nipulative therapy as indicated. The other article by der pain28 and gastroesophageal reflux disease.29 Bryner16 describes five cases of unilateral flank pain and local tenderness attributed to involvement of the quadra- Clinical presentation tus lumborum muscle. Chiropractic treatment consisted of In a recent article, Schneider30 wrote that tender spots soft tissue therapies and spinal manipulation. In all five (TSs) differ from trigger points (TPs) in that TSs are de- cases, patients reported significant improvement within fined as discrete areas of soft tissue that are painful to the first few days of treatment, although two patients re- about 4 kg ofdigital pressure. By contrast, TPs are defined quired 4 to 6 weeks of treatment in order to experience as hyperirritable spots located within the taut band of skel- sustained pain relief and return to normal function.16 etal muscle that are painful to compression and give rise to These reports are congruent with the current literature that characteristic referred pain patterns and autonomic symp- suggests the QL is the most important stabilizer of the low toms.26'30 Both tender spots and trigger points may simul- back.17,18 taneously exist in muscle, tendon, ligament, fascia or In addition to ischemic compression, (see also 19) other fibrous articular capsules. modalities have been successfully applied to elicited trig- Trigger points often give rise to characteristic pattern of 258 J Can Chiropr Assoc 2002; 46(4) G Hains

referred pain distant from the point of contact.31 The pain dermal nerve endings related to involved dermatomes elicited is diffuse and radiates to an area representing the could release enkephalins that, in turn, bind to the symptomatic site.31 In almost all cases, digital pressure on receptors of capaicin-sensitive fibers thus preventing the the painful point will reproduce the symptoms of the chief release of substance p.8 This deactivates nociceptive neu- complaint, or even worsen the level ofreported pain. Inac- rons and inhibits the mechanism involved in the patho- tivation of either TPs or TSs, however, may eradicate the physiology of low back pain. Moreover, these researchers patient's pain. WhenTPs and TSs are localized in a palpa- suggest that structures in the thalamus and brainstem acti- ble group of contracted muscle fibers, they may feel like a vated by stimuli applied far from the painful zone are hypersensitive band. That group of fibers is called a taut capable of triggering pain-relieving effects.8 band.26 In chiropractic, the most common method of treating Management approach these tension points is the use of sustained thumb pressure, Favouring as they do techniques that are low-tech, non- called ischemic compression (see below). invasive and hands-on, chiropractors typically use cryo- therapy, mobilization, manipulation and soft tissue Possible biological mechanisms techniques for the management of disorders of the spine Many historians credit Nimmo with being the first and peripheral joints.2'3 Among the most popular method chiropractor to make what was, for its time, a radical con- of treatment of myofascial pain syndromes is ischemic ceptual leap from a treatment model advocating 'moving compression. This approach, also known as Pennel's tech- bones' to one that addressed the muscles that move the nique, Nimmo technique, trigger point therapy or bones.33 Nimmo, a pioneer in the area of soft tissue tech- acupressure has been used by chiropractors and other niques, theorized that hypersensitive areas, equivalent to manual therapists for at least 40 years.2 According to the the trigger points described by Travel, were abnormal 2000 Job Analysis of the National Board of Chiropractic neurological reflex arcs.32 According to Gatterman and Examiners, over 90% of chiropractors use trigger point Lee,34 Nimmo referred to the inter-relationship of muscle therapy for passive adjustive care, 68% use acupressure, tonus and the central nervous system as 'reverberating and 40% report using NIMMO or Receptor tonus tech- circuits', whereby the stimulus was self-perpetuating until nique.2 It should also be mentioned chiropractors often the cycle was broken. Nimmo posited that what he re- provide patient education, lifestyle modifications and ferred to as hypermyotonia may result from trauma, expo- ergonometric suggestions to augment the care adminis- sure to cold drafts, or from occupations requiring an tered in the office.2 individual to maintain a prolonged period of postural strain such as typing or driving an automobile.33 The net Locating triggerpoints effect of this increased sensory input to the spinal cord As suggested by Travel and Simons,31 a practitioner lo- resulted in increased streams of efferent impulses to mus- cates trigger points by using the tip of his or her thumb to cles, resulting in a constant state of abnormal contraction. exert a pressure of about 4 kg on the muscles and tendons In turn, this abnormal contraction led to a further increase of the low back. Several experts have developed different in aberrant sensory input and still more muscle contrac- strategies to help a practitioner identify the trigger points tion. This process was thought to occur in the sympathetic and tender spots most associated with low back pain. nervous system, and was thus beyond voluntary control. Simons9 locates these trigger points by relying on the However, unlike Travel and Simons who advocated injec- characteristic manner in which elicited pain is distributed tions to trigger points, spray and stretch techniques and throughout the low back. The author of this article goes ischemic compression, Nimmo did not address the trigger further, suggesting a practitioner examine the entire point directly, instead suggesting that the sequential appli- symptomatic region of the patient's low back, trying to cation of pressure to affected muscles would cause the identify TPs, TSs and taut bands. With regard to the low nervous system to 'release a hypertonic muscle'.33 back, the author applies thumb-tip pressure to each square Kovacs and his colleagues suggest that there is evi- inch of the lumbar spine and hip area (with the obvious dence to support the theory that physical stimulation of exception of the genital area). The author also investigates J Can Chiropr Assoc 2002; 46(4) 259 Low back pain

the femoral trochanters, sacrum and sacroiliac joints. This 4 cm by either the practitioner's knee or using a pelvic examination is conducted during the initial examination block. Due to the anatomical proximity of the sciatic and elicited TGs and TSs are appropriately recorded in the nerve, this area should be examined whenever a patient patient's health history file. reports sciatic. It is not uncommon for piriformis Since various muscles overlap, the author also relies on hypertonicity to mimic sciatica of discal origin.9'31 specific skeletal reference points that are well known and 6. The gluteus minimus (Figure 6). Examination and easily located. If necessary, specific muscle tests can be treatment of this muscle is performed by positioning performed to better differentiate between overlapping the patient on his or her side. The examiner may stand muscles. A description of a method to locate and identify either in front of or behind the patient. In cases involv- the most common sites of trigger points and tender spots ing the gluteus minimus muscle, the patient often re- associated with low back pain is described below. ports of pain in the outer aspect of the thigh. 7. The ischium (Figure 7), femoral trochanters (Figure 8) Sites examined and anterior iliac crest (Figure 9), although less com- 1. The quatratus lumborum (see Figure 1). Although the monly involved, should each be individually examined QL muscle is a common cause of low back pain, it is as well. often overlooked by practitioners. The patient is placed Different muscles may overlap. To better differen- in the prone position. The practitioner may raise the tiate between one muscle and another, the suspected patient's pelvis by 2 to 6 cm (on the side of examina- muscle can be tested for its strength. For example, al- tion) using a knee or pelvic wedge and palpates the though the piriformis muscle and gluteus minimus entire QL muscle from the inferior aspect of the 12th muscle may both exhibit trigger points in close prox- rib to the ipsilateral iliac crest. imity to each other, the former is an external rotator of 2. The posterior superior iliac spine (PSIS). Trigger the leg, whereas the latter is an abductor and weak points are often located in close proximity to this struc- extensor of the pelvis.36 ture, and within a 2 cm radius of it. The author has observed that most patients suffering from low back Treatment have trigger points at this site (Figure 2). Once TPs and TSs are identified, the author applies 3. The iliac crest (see Figure 3). This structure is palpated ischemic compression for between 5 and 15 seconds, de- moving from posterior to anterior. pending on patient tolerance. In the author's clinical 4. The wider aspect of the posterior sacroiliac line (see experience, it is useful to sustain pressure for a longer Figure 4). period of time on those trigger points found to be more 5. The piriformis area (see Figure 5). The trigger point of sensitive to digital pressure. However, the author has also this muscle can be found 3 cm lateral from the second found that the more trigger points the patient elicits, the sacral tubercle. Alternatively, an imaginary line can be less time each one should be treated. Again, this is moni- drawn from the PSIS to the greater trochanter of the tored by closely observing the patient's tolerance to the femur. The trigger point of the piriformis can often be pain. Each elicited TP or TS is treated during the course of located by contacting a point 1 to 2 cm below the mid- the patient's visit. The intensity of digital pressure by the way point of this line. Performing a Hibb's maneuver physician should induce local or referred pain that does can further isolate the piriformis muscle. To perform not cause the patient to attempt to break the contact or this test, the patient is placed in the prone position. The protect the muscle being treated by contracting it. The examiner bends the patient's leg to 90' and the thigh is treatment has to be painful but bearable. It is the author's internally rotated by externally rotating the leg.34 Thus, experience that only the symptomatic side should be while the examiner is performing this maneuver he or treated, and this general principle has been followed by she palpates the length of the piriformis from the other practitioners.(see 16,17) greater trochanter to the mid-sacral region. Treatments are provided to the patient until such time as The author has found it is easier to treat the piri- the identified TPs and TSs no longer elicit local or referred formis muscle when the patient's pelvis is raised about pain.27 This may require anywhere from 5 to 30 treatment 260 J Can Chiropr Assoc 2002; 46(4) G Hains

Quadratus lumborum Posterior superior iliac spine

I

Figure 1 Figure 2

Iliac crest Sacro-iliac articulation u U U U U a U U U U IU

Figure 3 Figure 4 J Can Chiropr Assoc 2002; 46(4) 261 Low back pain

Piriformis Gluteus minimus muscle Ischial tuberosity

Figure 5 Figure 6 Figure 7

Femur head Anterior iliac crest

Figure 9

Figure 8 262 J Can Chiropr Assoc 2002; 46(4) G Hains

sessions.27 The patient can be given a home-care stretch- 6 Cooperstein R, Perle SM, Gatterman MI, Lantz C, ing and strengthening program to further enhance recov- Schneider MJ. Chiropractic technique procedures for There are no contraindications to this treatment specific low back conditions: Characterizing the literature. ery.19 J Manipulative Physiol Ther 2001; 24(6):407-424. approach, and the only significant adverse effects reported 7 Hawk C, Long CR, Boulanger KT, Morschhauser E, Fuhr by patients is soreness or stiffness and, more rarely, some A. Chiropractic care for patients aged 55 years and older: minor bruising in the area being treated. In these cases, the Report from a practice-based program. J Am Geriatr Soc examiner can use less pressure on each TP or TS during 2000; 48:534-545. subsequent treatments. 8 Kovacs FM, Abraira V, Pozo F et al. Local and remote sustained trigger point therapy for exacerbations of chronic low back pain. A randomized, double-blinded, controlled, Summary multicenter trial. Spine 1997; 22(7):786-797. Myofascial pain syndromes should be considered in all 9 Simons DG, Travel JG. Myofascial origins of low back patients reporting low back pain. Chiropractors should pain. Principles of diagnosis and treatment. Post graduate carefully assess the lumbar spine, as well as the gluteal, medicine 1983; 73:66-77. 10 Immamura ST, Fisher AA, Immamura M. Pain femoral and pelvic regions, attempting to elicit those TPs management using myofascial approach when other and TSs that reproduce the patient's chief complaint. treatment failed. Phys Med Rehab Clin North America Even in cases involving other causes of low back pain 1997; 8:179-97. (joint dysfunction, discal disease and so on), the practi- 11 Garvey TA, Marks MR, Wiesel SW. A prospective tioner may augment the patient's recovery by addressing randomized double-blind evaluation of trigger-points involved soft tissues. Ischemic compression is a safe and injection therapy for low back pain. Spine 1989; 14:962-964. effective method to successfully treat elicited trigger 12 Cassissi JE, Sypert GW, Lagana L et al. Pain, disability points or tender spots. This method does not require spe- and psychological functioning in chronic low back pain cialized equipment, it is well tolerated by the patient, and subgroups: myofascial versus herniated disc syndrome. is not physically strenuous on the doctor. Although there Neurosurgery 1993; 33:379-385. exists some evidence to support this clinical approach, 13 Shaw LJ. The role of the sacroiliac joint as a cause of low back pain and dysfunction. Presented at the World randomized controlled double-blinded studies or carefully Congress on Low Back Pain, University of California, San monitored practice-based clinical trials should be con- Diego, CA. Nov 5-6,1992. ducted in order to better substantiate the effectiveness of 14 Sandman KB. Myofascial pain syndrome: the mechanism, this approach observed in private practice. diagnosis and treatment. J Manipulative Physiol Ther 1981; 4:135-140. 15 Defranca GG, Levine LJ. The quatratus lumborum and Acknowledgement low back pain. J Manipulative Physiol Ther 1991; The author would like to thank Dr Brian Gleberzon D.C. 14(2): 142-149. for his assistance in preparing this manuscript. 16 Bryner PB. Unilateral back pain: a case series of quadratus lumborum involvement. Chiropractic Tech 1996; 8(2):70-77. References 17 McGill S. Low back exercise: evidence for improving 1 Vernon H, Cote P, Beauchemin D et al. International exercise regiments. Phys Ther 1998; 78:754-765. conference on spinal manipulation, 1990 FCER, 1701 18 Byfield D. Spinal rehabilitation and stabilization for the Clarendon Bouldvard, Arlington, Virginia. geriatric patient with back pain. In: Chiropractic Care of 2 Christensen MG. Job Analysis of Chiropractic. National the Older Patient (Gleberzon BJ editor). Butterworth- Board of Chiropractic Examiners 2000. Greeley, CO. Heineman, Oxford, UK. 2001; 407-440. 3 Meeker WC, Haldeman S. Chiropractic: A profession at 19 Hanten WP, Olsen SL, Butts NL, Nowicki AL. the crossroads of mainstream and alternative medicine. Effectiveness of a home program of ischemic pressure Ann Intern Med 2002; 136:216-227. followed by sustained stretch for treatment of myofascial 4 Vernon H. Spinal manipulation for chronic low back trigger points. Phys Ther 2000; 80(10):997-1003. pain: a review of the evidence. Top Clin Chirop 1999; 20 Alvarez DJ, Rockwell PG. Trigger points: diagnosis and 6(2):8-12. management. Am Fam Physician 2002; 65(4):653-660. 5 Hoffman B. Confronting psychosocial issues in patients 21 Esenyel M, Caglar N, Aldemir T. Treatment of myofascial with low back pain. Top Clin Chirop 1999; 6(2):1-7. pain. Am J Phys Med Rehabil 2000; 79(1):48-52.

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22 Han SC, Harrison P. Myofascial pain syndrome and 29 Hains G. Chiropractic management of shoulder pain and trigger-point management. Reg Anesth 1997; dysfunction of myofasical origin using ischemic 22(1):89-101. compression technique. J Can Chiropr Assoc 2002; 23 Hong CZ, Hsueh TC. Difference in pain relief after trigger 46(3): 192-200. point injection in myofascial pain patients with and 30 Schneider M. Tender points/ fibromyalgia vs. trigger without fibromyalgia. Arch Phys Med Rehabil 1996; points/ myofascial pain syndromes. A need for clarity in 77(11): 1161-1166. terminology and differential diagnosis. J Manipulative 24 Van Tulder MW, Cherkin DC, Berman B, Lao L, Koes Physiol Ther 1995; 18:398-406. BW. The effectiveness of acupuncture in the management 31 Travel JG, Simons DG. Myofascial pain and dysfunction. of acute and chronic low back pain. A systematic review The Trigger Point Manual. Second Edition. Williams and within the framework of the Cochrane Collaboration Back Wilkins, Baltimore. 1992 Review Group. Spine 1999; 24(11):1113-1123. 32 Norregaard J, Jacobsen S, Kristensen JH. A narrative 25 Cummings TM, White AR. Needling therapies in the review on classification of pain conditions of the upper management of myofascial trigger point pain: a systematic extremity. Scand J Rehab Med 1998; 31:153-164. review. Arch Phys Med Rehabil 2001; 82(7):986-992. 33 Cohen JH, Gibbons RW, Raymond L. Nimmo and the 26 Borg-Stein J, Stein J. Trigger points and tender points: one evolution of trigger point therapy, 1929-1986. and the same? Does injection treatment help? Rheum Dis J Manipulative Physiol Ther 1998; 21(3):167-172. Clin North Am 1996; 2292:305-322. 34 Gatterman M, Lee HK. Chiropractic adjusting technique. 27 Hains G, Hains F. Combined ischemic compression and In: Chiropractic: An illustrated history (Ed: Peterson D, spinal manipulation in the treatment of fibromyalgia: Weise G). Chicago, Mosby; 1995:240-261. A preliminary estimate of dose and efficacy. J Manipulative 35 McGee DJ. Orthopedic physical assessment. Third Ed. Physiol Ther 2000; 23:225-230. WB Saunders Co. Philadelphia, PA. 1997; 441. 28 Hains G, Hains F. Gastroesophageal reflux disease, spinal 36 Moore KL, Dalley AF. Clinically oriented anatomy. 4th manipulative therapy and ischemic compression: A ed. Lippincott, Williams and Wilkins. Baltimore, MA. prospective, clinical feasibility study. In press. 1999.

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